Healthcare Provider Details

I. General information

NPI: 1720014012
Provider Name (Legal Business Name): COASTAL GASTROENTEROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MEDICAL CENTER DRIVE
SUPPLY NC
28462
US

IV. Provider business mailing address

3 MEDICAL CENTER DRIVE
SUPPLY NC
28462
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-7790
  • Fax: 910-754-7838
Mailing address:
  • Phone: 910-754-7790
  • Fax: 910-754-7838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRANK LOVING HOLT JR.
Title or Position: MD
Credential: MD
Phone: 910-754-7790